rs3169 MI 457(b)/401(a) PROVIDER-TO-PROVIDER TRANSFER IN Governmental Plan Transfer from an account at another investment provider to MassMutual under the Plan listed below Account Number _____________________ Plan Name ____________________________________________________________________________________ Participant's Name ____________________________________________________________________________ first middle last Participant's Address ___________________________________________________________________________ street ___________________________________________________________________________ city state zip Social Security No. _______________________ Daytime Telephone #: ___________________________ E-mail Address: ___________________________________ TRANSFER INSTRUCTIONS I hereby request a transfer of the amount indicated below from my account at one of the investment providers available under my employer’s 457(b)/401(a) Plan to my 457(b)/401(a) Plan account with the Massachusetts Mutual Life Insurance Company (MassMutual). I understand that the investment provider that I am requesting the transfer from may require their own form for completion prior to executing the transfer. Amount of Transfer: Check one: Full Account Balance or Partial Account Balance: Amount to Transfer: $________________ Make Check payable to: Reliance Trust Company FBO: Participant Name ________________________________________________ Account Number: _____________________________________________________ Plan Name: __________________________________________________________ The transfer will be allocated among the investment options based upon your existing account investment elections with MassMutual. Transfer From: _______________________________________________________________ ____________________ Provider Account Number _______________________________________________________________ ____________________ Address Phone No.

TRANSFER INSTRUCTIONS · Daytime Telephone #: _ E-mail Address: _ TRANSFER INSTRUCTIONS. I hereby request a transfer of the amount indicated below from my account at one of

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Page 1: TRANSFER INSTRUCTIONS · Daytime Telephone #: _____ E-mail Address: _____ TRANSFER INSTRUCTIONS. I hereby request a transfer of the amount indicated below from my account at one of

rs3169 MI

457(b)/401(a) PROVIDER-TO-PROVIDER TRANSFER IN Governmental Plan

Transfer from an account at another investment provider to MassMutual under the Plan listed below

Account Number _____________________

Plan Name ____________________________________________________________________________________

Participant's Name ____________________________________________________________________________ first middle last

Participant's Address ___________________________________________________________________________ street

___________________________________________________________________________ city state zip

Social Security No. _______________________

Daytime Telephone #: ___________________________ E-mail Address: ___________________________________

TRANSFER INSTRUCTIONS I hereby request a transfer of the amount indicated below from my account at one of the investment providers available under my employer’s 457(b)/401(a) Plan to my 457(b)/401(a) Plan account with the Massachusetts Mutual Life Insurance Company (MassMutual). I understand that the investment provider that I am requesting the transfer from may require their own form for completion prior to executing the transfer.

Amount of Transfer: Check one: Full Account Balance or Partial Account Balance: Amount to Transfer: $________________

Make Check payable to: Reliance Trust Company FBO: Participant Name ________________________________________________ Account Number: _____________________________________________________ Plan Name: __________________________________________________________

The transfer will be allocated among the investment options based upon your existing account investment elections with MassMutual.

Transfer From:

_______________________________________________________________ ____________________ Provider Account Number

_______________________________________________________________ ____________________ Address Phone No.

Page 2: TRANSFER INSTRUCTIONS · Daytime Telephone #: _____ E-mail Address: _____ TRANSFER INSTRUCTIONS. I hereby request a transfer of the amount indicated below from my account at one of

rs3169 MI

PARTICIPANT SIGNATURE

I am a Participant in the governmental 457(b)/401(a) plan named above and want to transfer the amount indicated to MassMutual. This transfer is intended to qualify as a federal income tax-free direct transfer.

_______________________________________________________________ ____________________ Participant Signature Date

457(b)/401(a) PLAN ADMINISTRATOR

I authorize the above requested Provider-to-Provider Transfer of the Participant’s 457(b)/401(a) Plan account balance as indicated above. I certify that the Plan allows for Provider-to-Provider transfers.

____________________ __Not required__________________________________________________ Plan Administrator Signature Date

Mail this completed form and your check to MassMutual at the address listed below or fax the form to 816-701-8005 and mail your check separately.MassMutualPO Box 219062Kansas City MO 64121-9062For Overnight Mail: MassMutual 430 W 7th St Kansas City MO 64105